Laboratory Codes Bundled on OPPS Final Rule

Effective January 1, 2014 CMS began bundling payment of nearly all clinical laboratory tests performed on hospital outpatients into a single facility payment for primary hospital outpatient visits. This excludes molecular pathology tests, but does include the technical component of certain anatomic pathology (AP) services, as outlined in CMS’ Transmittal R2845CP. These services include CPT codes:

According to CMS, most laboratory tests provided in outpatient settings will be reimbursed under the Hospital Outpatient Prospective Payment System (HOPPS) and should be reported on a 13X type of bill, which is to be submitted by the hospital and not the laboratory. It will be the hospital’s job to determine patient status as an inpatient, outpatient or non-patient. This allows for the encounter to be billed separately if the service falls under the following criteria:

• Any test performed on a non-patient of the hospital. The current definition of non-patient says any beneficiary that is neither an inpatient nor an outpatient, but has a specimen presented for testing and the beneficiary is not physically present at the hospital• When the only services that a beneficiary receives are laboratory services. The patient does not receive any other outpatient services during the same encounter.• If the patient receives other outpatient services during the same encounter besides laboratory services, but the laboratory services are clinically unrelated to the reason for the outpatient encounter and are ordered by a different provider, bill on a 14X bill type.

CMS did not expect edits to be in place on the first of January, so denials due to this edit will likely not take place right off the bat. It is important for all pathology groups to work with the hospital to determine appropriate billing for each patient and ensure appropriate billing. Auditing of initial claims for the year should take place to determine compliance to this policy and appropriate action should take place when errors are found. If you have additional questions about this, please contact your Practice Manager.

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